Bipolar Disorder in Children and Adolescents - A Review of What is known.

Bipolar Disorder in Children and Adolescents:

A Review of What is known.

Tracey B. Katz

Intro. To Research Methods

Dr. Bernie Newman

11/10/02

Bipolar disorder is a brain disorder which causes shifts in moods, energy, and one’s ability to function on a daily basis. Bipolar disorder can further severely impair people’s capacity to perform on the job, in school, damage relationships, and even lead to suicide. “Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in it’s origins, yet one that feels psychological in the experience of it; an illness that is unique in converging advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide,”(NIMH, 2001). More than two million American adults, or about 1 percent of the population 18 and older in any given year have bipolar disorder, (NIMH, 2001.). Typically, it is diagnosed in late to early adolescence. In adults the bipolar continuum ranges from bipolar I, II, and cyclothymic disorder. These can be differentiated by the severity of the illness.

In recent years, more focus has been turned towards the diagnosis of bipolar disorder in children and adolescents. Bipolar disorder has been showing up in children and adolescents at an increasing rate and taken many mental health professionals by surprise. Approximately one million American children and adolescents suffer from this dreadful illness, (Kluger et al., 2002). However, while adults suffer across the bipolar continuum the literature suggest that children and adolescents display symptomatology of the most severe form of the illness. The clinical presentation of bipolar disorder in children (manic) usually manifests itself as “. . . worsening of disruptive behavior, moodiness, difficulty sleeping at night, impulsivity, hyperactivity, . . . an inability to concentrate. . . . Episodic short attention span, low frustration tolerance, and explosive anger followed by guilt, sulkiness, depression, and poor school performance. . .”(Weller et. al.,1995). In a study of 10 six to 12 year olds diagnosed with mania by DSM-II-R criteria 50% reported primarily elated moods and 50% reported a primary irritable mood. All of the subjects reported restlessness; 90% decreased need for sleep, 70% visual hallucinations, 60% increase in sexual appetite, 50% reported increases in talkativeness, distractibility, flight of ideas, and auditory hallucinations. Finally, grandiosity was seen and reported in 20% of the children studied, (Weller et al., 1995). As is evident by the literature children and adolescents usually experience mixed episodes. A classic bipolar profile, as it appears in adults, is almost never seen in children. The literature further suggests one reason for the misdiagnosis, under diagnosis, and differential diagnosis of bipolar disorder in children and adolescents may be due to the lack of clarity of its clinical presentation. In child psychiatry, it is the exception rather than the rule for children to present with a single diagnosis.

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Three areas of consistent co-morbidity, across the literature in diagnosis among children and adolescents with bipolar disorder were ADHD, conduct disorder, ODD, and anxiety disorders. There is no single study which systematically assesses co-morbidity in manic children. In a study done by Wozniak and her associates, a 69% rate of conduct disorder was found in children meeting DSM-III-R criteria for bipolar disorder. Furthermore, 92% of the subjects were diagnosed with co-morbid ADHD, 54% had some anxiety disorder diagnosis, and 99% of the sample was diagnosed ODD, (Biederman et al., 1999). Another study of 68 manic children found that 26 (38%) children were also diagnosed with conduct disorder, 63 (93%) children had co-morbid ADHD, and 62 (91%) children had overlapping symptoms of ODD, (Faraone et al 1997). Finally, anxiety disorders have more recently been looked at as a co-morbid entity in children and adolescent with bipolar disorder. In a study looking specifically at this neglected co-morbidity, it was reported that of the 43 child and adolescent subjects studied only 10 were found not to be affected by some sort of anxiety disorder, (Masi et al., 2001). The fact that these overlapping illnesses exists presents further diagnostic problems for practioners in regards to differential diagnosis.

Whenever, looking at diagnosing one with a psychiatric illness practioners must rule out differential diagnosis due general medical conditions. However, in children and adolescents there is a secondary dilemma due to overlapping symptamatology in several of the above stated psychiatric illnesses. This is another reason kids may be initially misdiagnosed as primarily ADHD, ODD, or CD as opposed to having a diagnosis and being treated for bipolar disorder.

Prior work shows that mania and conduct disorder occur in children however, it isn’t clear whether or not it is one illness that “mimics the other or is truly the presence of both disorders. In a study of 192 children, symptomatology had been compared and contrasted between groups who had CD and mania and those with just mania. Youths having mania with and without CD had similar rates of ultra rapid cycling of 24%. Furthermore, clinical features in manic children with and without CD were strikingly significant. Only two manic symptoms differed significantly: physical restlessness and poor judgment were more common in those with CD + mania. Finally, there were few differences in the frequencies of CD symptoms between those with and without mania. Although children with CD + mania had higher rates of vandalism, it fell short of the statistical significance rate (p=.016), (Beiderman et al., 1999). These statements clearly emphasize how the overlapping of symptoms leads to children being misdiagnosed and therefore mistreated for their illnesses. In another study by Faraone, children were often misdiagnosed ADHD due to once again overlap of symptoms between ADHD and mania such as distractibility, talkativeness, and hyperactivity. Once again research is focused on whether or not children suffer from ADHD alone or in cohorts with bipolar disorder. In a group of 68 manic children, in which 62 were also diagnosed ADHD, clinical features such euphoria were reported 42% of the time, irritability 90%, increased activity and talkativeness 95%, and distractibility and impulsivity also 95% (Faraone et al., 1997). These were stated to symptoms both of ADHD and mania.

Across the literature, behavior disorders and anxiety disorders have been suggested to be markers for juvenile onset bipolarity. Faraone’s study suggests “. . . severe ADHD symptoms are predictive of subsequent bipolarity” (Faraone et al., 1997”. The question that continues to remain for me is these illnesses precursors for juvenile bipolarity, do the illnesses exist together as co-morbidity, or are they a new phenotype of bipolarity on the bipolar continuum? A conclusion in Kovac’s study is that the coexistence of conduct disorder in children with mania may be an actual subtype of an early marker for juvenile onset bipolar disorder (Kovac et al., 1995,). Finally, “Juvenile anxious bipolarity might constitute a putative phenotype within the entire spectrum of bipolar disorder” (Masi et al., 2001).

In conclusion, children are being misdiagnosed and under diagnosed at alarming rates. The question which seems to arise from this literature is what we should actually diagnose bipolar children as being. We are aware that when children suffer from bipolar disorder they usually experience the most severe form of the illness that adult’s experience. However, the literature also goes on to suggest that juvenile onset bipolar disorder can be further complicated by the several co-morbidities, which may be responsible for new subtypes that present different from “typical” adult bipolar clinical features. If children present with significantly different symptoms from adults most of the time, how can we continue to diagnose them by the standard DSM IV criteria? It is necessary to further explore this area of research and come up with a diagnostic criteria or tool that children and adolescents can be qualified under for the purposes of diagnosing bipolar disorder. Maybe if as practioners we can find better diagnostic criteria, than we can provide our youth with better treatment.

Bibliography

Biederman, Joseph., (1998). Resolved: Mania is mistaken for ADHD in prepubertal children. Journal of American academy of child & adolescent psychiatry, (37), (7), 1091-1099.

Biederman, J., Faraone, S., Chu, M., Woziak, J. (1999). Further evidence of Bidirectional overlap between Juvenile mania and conduct disorder in children. Journal of the American academy of child & adolescent psychiatry, (38), (4), 468-476.

Duffy, A., Alda, M., Kutcher, S., Fusee, C., Grof, P. (1998). Psychiatric symptoms and syndromes among adolescent children of parents with lithium-responsive or lithium-non-responsive bipolar disorder. American journal of psychiatry, (155), (3), 431-433.

Faraone, S., Biederman, J., Wozniak, J., Mundy, E., Mennin, D., O’Donnell, D. (1997) Is co-morbidity with ADHD a marker for juvenile-onset mania? Journal of the American academy of child & adolescent psychiatry, (36), (8), 1046-1055.

Geller, B., Bolhofner, K., Craney, J., Williams, M., Delbello, M.P., Gundersen, K. (2000). Psychsocial Functioning in prepubertal and early adolescent bipolar disorder phenotype. Journal of American academy of child & adolescent psychiatry, (39), (12), 1543-1548.

Klugger, J., Song, S., Simon, L. (2002). Young and bipolar. Time, (160), (8), 38-51.

Kovacs, M., Pollock, M. (1995) Bipolar disorder and co morbid conduct disorder in childhood and adolescence. Journal of the American academy of child & adolescent psychiatry, (34), (6), 715-723.

Masi., Gabriel., Toni., Cristina., Perugi., Guilio., Mucci., et al. (2001). Anxiety disorder in children and adolescents with bipolar disorder: A neglected co-morbidity. Canadian Journal of Psychiatry, 07067437, (46), (9), 1-12.

NIMH., (2001). Bipolar disorder. Retrieved October 27, 2002, from the

Weller, E., Weller, R., Fristad, M. (1995). Bipolar in children: Misdiagnosis, under diagnosis, and future directions. Journal of the American academy of child and adolescent psychiatry, (34), (6), 709-714.

Bipolar Disorder in Children and Adolescents - A Review of What is known.

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